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Twice-Weekly Briefing
Tuesday, October 13, 2026
Issue 261013-71
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The MOC Brief
Health policy, priced and translated for self-funded plan sponsors
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In This Edition
Five developments from the past two weeks, and what each one costs you.
| 1. | Members can sue the company that administers their claims | | 2. | Three price file publication dates, and the schemas are not ready yet | | 3. | North America's 2027 trend now sits above Aon's global average | | 4. | Hospitals and the Blues are fighting over what AI coding costs you | | 5. | A large TPA just retired two site of service reviews |
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| 1 · PLAN ADMINISTRATORS · October 9, 2026 |
| A Federal Appeals Court Revived a Suit Letting Plan Members Sue the Company That Administers Their Claims |
| The Ninth Circuit reversed a dismissal on October 9 and sent Melissa and Miles Black's proposed class action against IEC Group, which does business as AmeriBen, back to the district court in Idaho. In August 2023 AmeriBen wrote to both plaintiffs to say an associate had emailed a spreadsheet of their health information to one or more plan members. The letter listed six categories that may have been disclosed: first and last names, unique tracking numbers, provider names, claim numbers, dates of service, and amounts billed or paid. The district court had thrown the case out under Rule 12(b)(1), holding that the plaintiffs suffered no injury in fact. Judge Eric Tung wrote that the harm the plaintiffs allege "resembles a breach of confidence and contract that courts have long understood as providing a basis for a lawsuit," and that "Plaintiffs have alleged an injury here enough to give them standing." The panel decided standing only, at the pleading stage, and the eight counts are state law claims including negligence and breach of fiduciary duty, not ERISA claims. |
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MOC Perspective
Your claims administrator holds those same six fields on every one of your members, and this decision means one misdirected email can become a class action it has to defend rather than a notification letter it files away. The opinion never says who sponsored or funded this plan, and AmeriBen's own site describes over 60 years serving employer groups, which is the seat most self-funded plans fill with a vendor. Nothing here establishes that AmeriBen did anything wrong, because the court ruled only that the members may proceed. The question to settle is your administrative services agreement, and specifically who pays the defense costs when a members' class action names your vendor and reaches for your plan records.
What to do now
| ▪ | Ask your TPA in writing for every breach notification it has sent your members in the past 24 months, with the count of people in each. | | ▪ | Pull the indemnification and defense cost clauses out of your administrative services agreement within 30 days. | | ▪ | Confirm which of those six field types your vendor still sends by email, and require encryption on all six. |
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| Source: U.S. Court of Appeals for the Ninth Circuit, No. 25-5952, opinion filed October 9, 2026 |
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| 2 · PRICE DATA DEADLINES · October 7, 2026 |
| Three Agencies Set Three Publication Dates for Five New Price Files and Hedged Every Schema Date |
| The Labor, Health and Human Services, and Treasury departments issued FAQs About ACA and CAA Implementation Part 75 on October 7, setting the dates behind the Transparency in Coverage rules published a day earlier at 91 FR 63748. The In-network Rate and Allowed Amount files carry an applicability date of March 6, 2027, but the first ones are not due until April 1, 2027, quarterly after that. The Taxonomy and Text files apply September 6, 2027 and are first due October 1, 2027, with the Text file then updated within seven days of any change. The Utilization file is annual and first due July 1, 2028. Until the first new files are due, plans keep complying with the 2020 rules on schema version 2.0, and the Departments hedge every new schema date with the words "on or around": February 1, 2027 for the two rate files, June 1, 2027 for the other three, and May 2027 for the drug file. Schema work on that drug file starts in November 2026, with first publication in December 2027 and monthly after that. |
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MOC Perspective
Two kinds of date sit side by side in this calendar, and a plan that diaries only the publication dates leaves itself no build time at all. Your working deadline is February 1, 2027, when the schema you have to build against is supposed to exist, and the Departments hedged that one with the words "on or around." For a self-funded plan these files come out of your TPA or your carrier while the legal obligation stays with the plan, so the thing to settle now is who is accountable for a missed first file.
What to do now
| ▪ | Diary five dates this week: February 1, March 6 and April 1, 2027, then October 1, 2027 and July 1, 2028. | | ▪ | Email your TPA or carrier now to ask which of the six files they will produce, and whether they will build to schema 3.0 for the two rate files and schema 1.0 for the other four. | | ▪ | Add an April 1, 2027 performance date to your service agreement so a missed file has a named owner. |
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| Source: U.S. Departments of Labor, Health and Human Services, and the Treasury, FAQs About ACA and CAA Implementation Part 75, October 7, 2026 |
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| 3 · RENEWAL BENCHMARK · October 6, 2026 |
| Aon Put North America's 2027 Medical Trend at 9.2 Percent, Now Above Its Global Average |
| Aon forecast on October 6 that medical plan costs globally will rise by an average of 9 percent in 2027, down from the 9.8 percent it forecast for 2026 in its release of October 7, 2025. North America barely moved: its gross medical trend rate is "projected to decline slightly to 9.2%" for 2027, against the 9.3 percent Aon projected for the region for 2026. That leaves North America 0.2 points above the global average for 2027 after sitting 0.5 points below it for 2026. The large declines are elsewhere, with the Middle East and Africa falling from 15.3 percent to 12.2 percent and Asia-Pacific dropping to 9.7 percent, while Europe moves from 8.2 percent to 7.5 percent. Aon drew the figures from over 100 of its own locations that broker, administer or advise on employer-sponsored medical plans, and published no sample size and no field dates. Kathryn Davis, Aon's head of global benefits analytics, said employers "should not mistake moderation for relief." |
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MOC Perspective
That 9 percent headline is going to arrive in your renewal conversation as evidence that trend is easing, and for your region it is not. North America is the only figure on the release that touches your plan, there is no United States number anywhere in it, and the release never says which countries the region covers. Aon labels the figure a gross rate and does not define that term, so do not set it against a net projection your consultant has already handed you without asking which basis each number uses.
What to do now
| ▪ | Ask your broker before your next renewal meeting which region the trend figure in your packet covers, and reject any number labeled global. | | ▪ | Require every trend figure quoted to you before January 1 to state whether it is gross or net of plan design changes. | | ▪ | Strike the global 9 percent from your 2027 budget memo and use the 9.2 percent North America figure instead. |
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| Source: Aon, 2027 Global Medical Trend Rates release of October 6, 2026, with the 2026 forecast on its release of October 7, 2025 |
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| 4 · CLAIMS CODING · October 5, 2026 |
| Hospitals Put Their Own Arithmetic Against the Blues' Claim That AI Coding Tools Are Raising Your Costs |
| The American Hospital Association published a blog post on October 5 answering a Blue Cross Blue Shield Association report that ties hospitals' use of AI-enabled documentation tools to higher costs through increased coding intensity. AHA reports the Blues' figures as $942 million in added spending for BCBSA plans from 2023 to 2025, a rise of roughly 9 percent in per-member commercial inpatient costs between 2023 and 2024, and about 20 percent of that rise, some 1.8 percentage points, attributed to coding intensity. Every one of those figures reaches a reader through AHA, the party disputing them. AHA then ran the arithmetic the other way: footnoting a Health Care Cost Institute report for the point that inpatient facility care is about 17 percent of employer-sponsored health spending, it argues that on the Blues' own estimate "inpatient coding intensity contributed only about 0.3 percentage points to total commercial spending growth." AHA also says the Blues' analysis "does not appear to identify which claims involved AI tools rather than traditional documentation and coding processes." Authors Molly Smith and Jen Holloman wrote that "Accurate diagnosis capture is not a coding problem; it is a patient care imperative." |
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MOC Perspective
That 0.3 percentage point figure is AHA's arithmetic on the Blues' own estimate, built from their 1.8 points and that 17 percent inpatient share, so what you have is two trade associations arguing over one denominator while neither of them audits your claims. Your plan is the party actually paying, and your own data sits closer to hand than either report. Ask your TPA for your inpatient case mix index by year and your share of claims in the highest severity tier, because if your severity mix moved while your admission counts held flat, you know your own plan changed even if nobody can say which tool did it.
What to do now
| ▪ | Request your inpatient case mix index for 2023, 2024 and 2025 from your TPA, broken out by facility. | | ▪ | Compare your highest severity tier share across those three years and flag any facility that moved more than 2 points. | | ▪ | Add a coding validation review to your 2027 audit scope covering at least your top 10 inpatient facilities by spend. |
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| Source: American Hospital Association blog post of October 5, 2026, by Molly Smith and Jen Holloman |
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| 5 · SITE OF SERVICE · October 1, 2026 |
| UMR Retired Two Site of Service Review Policies and Will Change a Third on December 1 |
| UMR's October 2026 medical policy update bulletin, posted October 1, retired its site of service policies for office-based procedures and for screening colonoscopy procedures effective October 1, 2026, and retired its virtual upper gastrointestinal endoscopy policy the same day. A third site of service policy, the one covering outpatient surgical procedures, is listed as updated effective December 1, 2026, and the bulletin does not say what changed in it. UMR describes itself in that bulletin as "a third-party administrator (TPA) for self-funded plans" and "a wholly owned subsidiary of UnitedHealthcare." The bulletin defines a retired policy as one whose services are no longer being managed, or are considered proven and medically necessary, which means they are not excluded on those grounds unless another policy documents criteria. It also says the absence of a policy does not automatically imply coverage, and that coverage is determined under the member's benefit plan. |
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MOC Perspective
Site of service review is the control that keeps a procedure out of a hospital outpatient department when an office or a surgery center can do it, and two of those reviews at this administrator stopped on October 1, alongside a retired virtual upper gastrointestinal endoscopy policy. The bulletin tells you the services are no longer being managed; it does not tell you what replaces the review, and it says plainly that the absence of a policy does not imply coverage. For a self-funded plan the dollars move before the paperwork does, so the one change still ahead of you is the outpatient surgical policy, and it is worth reading before it takes effect.
What to do now
| ▪ | Ask UMR for the claim volume and allowed dollars that ran through both retired reviews in the 12 months before October 1. | | ▪ | Request the updated outpatient surgical site of service policy before November 15. | | ▪ | Check within 30 days whether any other policy still documents site of service criteria for office-based procedures. |
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| Source: UnitedHealthcare provider resource library, UMR Medical Policy Update Bulletin for October 2026, posted October 1, 2026 |
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The Bottom Line
Four of these five stories land on one line of your plan: the contract with the company that administers it. Your TPA is the party a court just said members may sue over a disclosure, the party that has to build the new price files on the Departments' calendar, the party holding the case mix data that tells you whether your own severity mix moved, and the party that just retired two site of service reviews without saying what replaces them. None of those four moves on its own; each one moves when you put a date and an owner in the agreement. The cost of waiting is that all four get decided by your vendor's default instead of your plan's instruction.
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Jude Odu
Founder and Principal, Model Optimal Care
Author of Model Optimal Care: End U.S. Healthcare Waste, One Health Plan at a Time
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